Emergency Contact Form

Emergency Contact Information Form

Please fill out the form correctly
Employee Information
Employee Name:

First Name MILast Name
Cell Phone:

Area CodePhone Number
Date of Birth:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact #1
Name:

First NameLast Name
Phone #1:

Area CodePhone Number
Phone #2:

Area CodePhone Number
Emergency Contact #2
Name:

First NameLast Name
Phone #1:

Area CodePhone Number
Phone #2:

Area CodePhone Number
Law prohibits Cotton from requesting Protected Health Information (PHI); however, some PHI can be helpful to first responders in an emergency situation. As such, Cotton strongly recommends that you disclose any pertinent medical and/or health conditions (such as allergies, location of treatment devices, medications) to your emergency contact, set up your mobile device with such information, and/or utilize a medical bracelet.
Medical Contact Information
Doctor's Name:
Doctor's Number:

Area CodePhone Number
*Please provide a copy of the inside cover of your passport or passport card and shot record to the human resources department (hrteam@cottonteam.com).
I, the undersigned, do hereby authorize Cotton, its affiliates, and any employees, officers, agents or delegees of Cotton or its affiliates (“Cotton”) to contact directly the person(s) named on this form and do authorize the named individuals to authorize any treatment as may be deemed in an emergency. In the event where the named individuals cannot be reached expeditiously, I hereby authorize Cotton to make necessary decisions for my health and welfare in an emergency event and hereby fully release and hold harmless Cotton for such actions. If completed and signed electronically, I warrant the accuracy of the information provided.
Employee Signature:

Clear
Print Your Name Here:
Date of Signature:

MonthDayYear
Date
Last Revised: 08/08/2018
Sender's Name:
Should be Empty:

Emergency Contact Information Form